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Background: Conventional operative insufflation uses a one-way trocar to handle instruments while maintaining pneumoperitoneum. In 2007, the AirSeal® valveless trocar insufflation system was introduced, which maintains stable pneumoperitoneum while continuously evacuating smoke. Although this device has been validated in adult patients, it has not been extensively validated in the pediatric population. Materials and Methods: A retrospective cohort study of pediatric urology patients aged 0 to 21 who underwent laparoscopic pyeloplasty between March 2016 and October 2021 was performed. Intraoperative physiologic parameters, procedure characteristics, postoperative outcomes, and demographics of each patient in whom either AirSeal insufflation system (AIS) or conventional insufflation system (CIS) was utilized were obtained from hospital records. Data were compared across the AIS and CIS cohorts. The primary outcomes were intraoperative anesthetic and physiologic parameters, including end tidal carbon dioxide, oxygen saturation, body temperature, positive inspiratory pressure, systolic blood pressure, and heart rate. Results: There were no significant differences in the anesthetic and physiologic parameters in the AIS and CIS groups. In addition, no differences in demographics, procedural characteristics, or complication rates were found between the cohorts. Conclusion: The AirSeal valveless trocar insufflation system demonstrates comparable intraoperative anesthetic and physiologic outcomes compared to conventional one-way valve insufflation in pediatric laparoscopic pyeloplasty. Certain surgeon-related qualitative metrics are underappreciated in this study, however, including improved visualization with vigorous suctioning and pressure maintenance with frequent instrument exchanges. Surgeon experience may mask the benefits of these characteristics as it pertains to quantitative surgical outcomes such as estimated blood loss, operative time, and perioperative complications.
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Anestésicos , Insuflação , Laparoscopia , Pneumoperitônio , Urologia , Adulto , Humanos , Criança , Insuflação/métodos , Estudos Retrospectivos , Laparoscopia/métodos , Instrumentos Cirúrgicos , Dióxido de Carbono , Pneumoperitônio Artificial/métodosRESUMO
PURPOSE: Nivolumab received US Food and Drug Administration approval as a single agent or in combination with ipilimumab in patients with microsatellite instability-high/mismatch repair-deficient (MSI-H/dMMR) metastatic colorectal cancer (mCRC) that progressed following treatment with a fluoropyrimidine, oxaliplatin, and irinotecan based on CheckMate 142. Presented are results of nivolumab plus low-dose ipilimumab in the first-line therapy cohort from the phase II CheckMate 142 study. PATIENTS AND METHODS: Patients with no prior treatment in the metastatic setting for MSI-H/dMMR CRC were treated with nivolumab every 2 weeks plus low-dose ipilimumab every 6 weeks until disease progression. The primary end point was objective response rate (investigator assessment; RECIST v1.1). RESULTS: Median age of treated patients was 66 years (N = 45). Median follow-up was 29.0 months. Objective response rate and disease control rate were 69% (95% CI, 53 to 82) and 84% (95% CI, 70.5 to 93.5), respectively, with 13% complete response rate. Median duration of response was not reached; 74% of responders had ongoing responses at data cutoff. Median progression-free survival and median overall survival were not reached with minimum follow-up of 24.2 months (24-month rates, 74% and 79%, respectively). Clinical benefit was observed regardless of baseline demographic and tumor characteristics, including BRAF or KRAS mutation status. In a post hoc analysis, of 14 patients who discontinued treatment and did not receive subsequent therapy, 10 remained progression-free. Patient-reported outcomes were stable over the treatment period. Grade 3-4 treatment-related adverse events occurred in 22% of patients; 13% discontinued because of any-grade treatment-related adverse events. CONCLUSION: Nivolumab plus low-dose ipilimumab demonstrated robust and durable clinical benefit and was well tolerated as a first-line treatment for MSI-H/dMMR mCRC. Based on these promising data, randomized studies are warranted.
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Protocolos de Quimioterapia Combinada Antineoplásica/administração & dosagem , Neoplasias Colorretais/tratamento farmacológico , Reparo de Erro de Pareamento de DNA , Inibidores de Checkpoint Imunológico/uso terapêutico , Ipilimumab/administração & dosagem , Instabilidade de Microssatélites , Nivolumabe/administração & dosagem , Adulto , Idoso , Idoso de 80 Anos ou mais , Protocolos de Quimioterapia Combinada Antineoplásica/efeitos adversos , Neoplasias Colorretais/genética , Neoplasias Colorretais/imunologia , Neoplasias Colorretais/mortalidade , Progressão da Doença , Feminino , Humanos , Inibidores de Checkpoint Imunológico/efeitos adversos , Ipilimumab/efeitos adversos , Masculino , Pessoa de Meia-Idade , Metástase Neoplásica , Nivolumabe/efeitos adversos , Intervalo Livre de Progressão , Fatores de Tempo , Adulto JovemRESUMO
BACKGROUND: Various treatment modalities have been used in treating femoral shaft fractures, i.e., open intramedullary nailing, plating and external fixators but these does not always produce stable fixation and there is increased risk of infection, closed locked intramedullary nailing technique has being the gold standard and is a routine procedure but it requires proper orthopedic operation table with traction apparatus and the use of image intensifier. The use of open interlocking nailing technique doesn't require any special orthopaedic table nor it requires use of Image intensifier. The objective of this study is to find out and determine the frequency of fracture union and wound infection in open reamed interlocking nailing of close fractures of shaft of femur. METHODS: This study included fifty-eight patients from either gender, above 14 years of age with closed femoral shaft fracture presenting within 2 weeks. Data was collected on Performa about gender, age, address, date of fracture, date of operation and discharge, type of fracture and follow-up visits. RESULTS: Mean age of the patients were 31.24±8.662. According to Winquist & Hansen, femur shaft fractures were divided into four types. Type I were found in the 16(27.6%), Type II in 21 (36.2%), Type III in 12 (20.7%) and Type IV in 9 (15.5%). Total number of fracture union with regard to Winquist & Hensen Classification of fracture shaft femur were, Type I, 14 (24.1%), Type II, 21 (36.2%), Type III, 12 (20.7%), Type IV, 8 (13.8%) respectively while the rest 3 (5.2%) were found in non-union. Total number of fracture union with regard to gender of the patients were, 41 (70.7%) males and 14 (24.1%) were females while the rest 3 (5.2%) patients fracture union has not occurred. Fracture union was found in 55 (94.8%) out of 58 patients; while fracture union had not occurred in 3 (5.2%) out of 58 patients. The total number of patients who developed wound infection following surgery were 5 (8.6%) out of 58 patients; while the non-infected patients were 53 (91.4%) out of 58 patients. CONCLUSIONS: The open interlocking nailing technique for close fractures shaft of femur without the use of image intensifier achieved excellent results in terms of fracture union. Results obtained are mostly similar to the results of close interlocking nailing and it also requires less expertise, recourses and without the use of image intensifier.
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Fraturas do Fêmur/cirurgia , Fixação Intramedular de Fraturas/métodos , Consolidação da Fratura , Fraturas Fechadas/cirurgia , Adolescente , Adulto , Pinos Ortopédicos , Diáfises/lesões , Diáfises/cirurgia , Feminino , Fixação Intramedular de Fraturas/efeitos adversos , Fraturas não Consolidadas/etiologia , Humanos , Masculino , Pessoa de Meia-Idade , Infecção da Ferida Cirúrgica/etiologia , Resultado do Tratamento , Adulto JovemRESUMO
Traumatic tricuspid regurgitation (TR) is a rare cause of acute right ventricular dysfunction. The surgical technique could be complex and the reparative gesture has a lower success rate when compared with functional TR. We present the case of a 26-year-old male patient with traumatic TR who underwent tricuspid valve repair, with an initial satisfactory result. Later, the onset of acute severe residual TR was observed and the valve needed to be replaced. Surgery is the mainstay of treatment for traumatic TR, either in the form of repair or replacement. It requires an early diagnosis and concomitant treatment of injuries.
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Anuloplastia da Valva Cardíaca/métodos , Implante de Prótese de Valva Cardíaca/métodos , Insuficiência da Valva Tricúspide/etiologia , Insuficiência da Valva Tricúspide/cirurgia , Valva Tricúspide/cirurgia , Ferimentos e Lesões/complicações , Acidentes por Quedas , Adulto , Diagnóstico Precoce , Humanos , Masculino , Resultado do Tratamento , Insuficiência da Valva Tricúspide/diagnósticoRESUMO
OBJECTIVE: To provide, with the use of preoperative coronary computed tomography angiography, an in vivo anatomical characterization of the relationship between the circumflex artery and mitral valve annulus to identify different risk classes and to increase the surgical awareness of those anatomical relations. METHODS: Ninety-five (mean age: 64.2 ± 11.7) consecutive patients, initially referred for elective minimally invasive mitral valve surgery, underwent preoperative coronary computed tomography angiography. The distance between the circumflex artery and mitral annulus was assessed using 6 points designed on the posterior mitral annulus, starting from the anterolateral to the posteromedial commissure; this design created an ideal 5-zone system. High-risk anatomy was defined as a distance less than 3 mm between the circumflex artery and the mitral valve annulus. RESULTS: The shortest distance between the circumflex artery and mitral valve annulus was observed at the area between the anterolateral commissure and the midpoint of P1 scallop, so-called zone 1 (5.49 ± 3.13 mm), whereas the longest distance occurred at zone 5 (12.03 ± 4.93). Twenty-four patients (25%) were identified with high-risk anatomy (mean distance 1.94 ± 0.8 mm). Left dominant and co-dominant hearts demonstrated a shorter circumflex artery-mitral valve annulus distance at all the zones. At multinomial logistic regression, the pattern of coronary dominance and the size of the circumflex artery were independent factors for high-risk anatomy. CONCLUSIONS: Coronary computed tomography angiography is a useful investigation to identify patients at risk of circumflex artery flow disturbance; for high-risk anatomy, this knowledge may enhance a safer operative technique.
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Lactic acidosis is a potentially life-threatening complication characterized by accumulation of blood lactate resulting in low arterial pH. The majority of lactic acidosis in malignancies are reported in association with hematologic malignancies. It may result from an imbalance between lactate production and hepatic lactate utilization, but the exact pathophysiology is far more complex than what we can fathom from current micromolecular studies. We report a case of a 71-year-old male with metastatic lung cancer presenting with fatal lactic acidosis in the absence of liver involvement. Review of the literature reveals only 27 reported cases of solid tumors presenting with lactic acidosis, of which nearly all of them had extensive liver metastasis. Patients were treated with aggressive fluid resuscitation, bicarbonate administration and hemodialysis, but the only effective treatment modality was early aggressive chemotherapy initiation.
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Acidose Láctica/etiologia , Neoplasias/complicações , Idoso , Humanos , Masculino , Neoplasias/diagnóstico por imagem , Tomografia Computadorizada por Raios XRESUMO
BACKGROUND: Brain metastases are one of the most malignant complications of lung cancer and constitute a significant cause of cancer related morbidity and mortality worldwide. Recent years of investigation suggested a role of LKB1 in NSCLC development and progression, in synergy with KRAS alteration. In this study, we systematically analyzed how LKB1 and KRAS alteration, measured by mutation, gene expression (GE) and copy number (CN), are associated with brain metastasis in NSCLC. MATERIALS AND METHODS: Patients treated at University of North Carolina Hospital from 1990 to 2009 with NSCLC provided frozen, surgically extracted tumors for analysis. GE was measured using Agilent 44,000 custom-designed arrays, CN was assessed by Affymetrix GeneChip Human Mapping 250K Sty Array or the Genome-Wide Human SNP Array 6.0 and gene mutation was detected using ABI sequencing. Integrated analysis was conducted to assess the relationship between these genetic markers and brain metastasis. A model was proposed for brain metastasis prediction using these genetic measurements. RESULTS: 17 of the 174 patients developed brain metastasis. LKB1 wild type tumors had significantly higher LKB1 CN (p<0.001) and GE (p=0.002) than the LKB1 mutant group. KRAS wild type tumors had significantly lower KRAS GE (p<0.001) and lower CN, although the latter failed to be significant (p=0.295). Lower LKB1 CN (p=0.039) and KRAS mutation (p=0.007) were significantly associated with more brain metastasis. The predictive model based on nodal (N) stage, patient age, LKB1 CN and KRAS mutation had a good prediction accuracy, with area under the ROC curve of 0.832 (p<0.001). CONCLUSION: LKB1 CN in combination with KRAS mutation predicted brain metastasis in NSCLC.
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Neoplasias Encefálicas/secundário , Carcinoma Pulmonar de Células não Pequenas/genética , Carcinoma Pulmonar de Células não Pequenas/patologia , Genes ras , Neoplasias Pulmonares/genética , Neoplasias Pulmonares/patologia , Mutação , Proteínas Serina-Treonina Quinases/genética , Quinases Proteína-Quinases Ativadas por AMP , Adulto , Idoso , Idoso de 80 Anos ou mais , Biomarcadores Tumorais , Análise Mutacional de DNA , Feminino , Dosagem de Genes , Expressão Gênica , Humanos , Masculino , Pessoa de Meia-Idade , Estadiamento de Neoplasias , Razão de Chances , Prognóstico , Curva ROC , Fatores de RiscoAssuntos
Antineoplásicos/uso terapêutico , Rearranjo Gênico , Transtornos Mieloproliferativos/tratamento farmacológico , Transtornos Mieloproliferativos/genética , Cromossomo Filadélfia , Piperazinas/uso terapêutico , Pirimidinas/uso terapêutico , Receptor beta de Fator de Crescimento Derivado de Plaquetas/genética , Benzamidas , Humanos , Mesilato de Imatinib , Hibridização in Situ Fluorescente , Masculino , Pessoa de Meia-Idade , Resultado do TratamentoRESUMO
BACKGROUND: Studies of octreotide in hepatocellular carcinoma have yielded conflicting results. Since past studies have excluded patients with highly advanced disease and given the fact that octreotide offers several potential physiologic benefits in patients with advanced cirrhosis, such as improving renal physiology and decreasing portal venous pressure, we designed a trial to examine the survival of patients with both advanced HCC and advanced cirrhosis as defined by a CLIP score of 3 or higher. PATIENTS AND METHODS: The study was designed as a phase-II, multicenter trial, enrolling patients with advanced HCC in three tertiary care academic centers in the United States. The primary objective was to verify whether long-acting octreotide will extend median survival from 5 months to 8.75 months for patients with CLIP scores of 3 or higher, representing a 75% increase in median survival time. Secondary objectives included assessing safety and tolerability in this patient population. RESULTS: Twenty-two patients were enrolled from 2003 to 2005. The mean age was 66, with the majority of patients being men. The median CLIP score was 4 with a median KPS of 80%. Ten of 22 patients died without evidence of progression of HCC. The median TTP was 5.7 months (95% confidence interval [CI], 2.8-10.7). The median PFS time was approximately 3 months (95% CI, 1.7-5.7). The median OS time was 4.5 months (95% CI, 2.3-8) and therefore did not meet the established primary end point. Six of 22 patients achieved an OS of greater than 10 months. One patient experienced a radiographic partial response. CONCLUSIONS: Long-acting octreotide was not associated with a survival benefit in patients with significant liver disease related to HCC. The identification of one patient with disease regression and a subgroup of patients with significantly greater survival underscores the need to gain a better understanding of the role of somatostatin receptors on HCC cells before further clinical testing of this drug in HCC patients.
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Colorectal cancer (CRC) remains one of the most frequent cancer diagnoses and a leading cause of cancer-related deaths in the United States. Significant progress, however, has been made since the advent of single-agent 5-fluorouracil therapy. The addition of irinotecan and oxaliplatin to the cytotoxic armamentarium, mostly given in combination, has dramatically improved response rates, progression-free survival, and overall survival (OS). In recent years, the addition of biologic therapies, including bevacizumab, cetuximab, and panitumumab, has further contributed to improved outcomes. There have been recent data suggesting that sequential cytotoxic therapy, in the majority of patients, provides similar outcomes with regard to OS compared with combination chemotherapy. However, because of several limitations in the FOCUS and CAIRO trials, the data are difficult to apply to current treatment regimens. Although these data do help us further define patients who may benefit from sequential chemotherapy, the standard of care remains combination chemotherapy in the vast majority of patients. This approach will be further refined as progress is made in pharmacogenomics and in prognostic and predictive factors in treating patients with metastatic CRC.
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Antineoplásicos/administração & dosagem , Protocolos de Quimioterapia Combinada Antineoplásica , Neoplasias Colorretais/tratamento farmacológico , Neoplasias Colorretais/mortalidade , Neoplasias Colorretais/patologia , Intervalo Livre de Doença , Humanos , Resultado do TratamentoRESUMO
Often, the problem in cancer research is figuring out how a gene or pathway works in regulating cellular transformation. The question of what RAS activates or PTEN inhibits have been classic dilemmas of modern cancer biology. In these cases, biochemical and genetic studies have provided us with a fairly clear picture of the cancer relevant functions of these genes. For LKB1, a more recently identified human tumor suppressor gene, however, the problem is different. This serine-threonine kinase that is conserved from yeast to mammals seems to play a role in many diverse cellular pathways. Therefore, although elegant functional and genetic approaches have established critical roles for LKB1 in the regulation of metabolism, motility, polarity, and the cell cycle, the role(s) responsible for its true tumor suppressor function(s) is unknown. One is reminded of an Agatha Christie murder mystery where nearly every character in the book has reason to be suspected of committing the crime-there are too many suspects for how LKB1 might repress lung cancer.